What is the treatment for kratom withdrawal?

Treatment for Kratom Withdrawal

Buprenorphine-naloxone is the most effective first-line treatment for kratom withdrawal, with dihydrocodeine and lofexidine as effective alternatives for managing opioid-like withdrawal symptoms. 1, 2

Understanding Kratom Withdrawal

Kratom (Mitragyna speciosa) contains alkaloids that act as partial μ-opioid receptor agonists and κ-opioid receptor antagonists, producing opioid-like effects at higher doses. When discontinued after chronic use, it can lead to withdrawal symptoms similar to those seen with traditional opioids.

Common Withdrawal Symptoms:

• Anxiety and restlessness
• Tremors and sweating
• Muscle aches and pain
• Sleep disturbances
• Nausea and vomiting
• Drug cravings
• Irritability

Assessment and Monitoring

• Use standardized opioid withdrawal assessment tools (such as COWS - Clinical Opioid Withdrawal Scale)
• Monitor vital signs regularly, particularly when using medications
• Assess for adequate hydration and nutrition
• Screen for polysubstance use, as kratom is often used with other substances

Treatment Algorithm

Step 1: Non-pharmacological Support

• Ensure adequate hydration
• Nutritional support
• Minimize environmental stimuli
• Supportive counseling

Step 2: Pharmacological Management

First-line Treatment:

• Buprenorphine-naloxone:
  • Induction: 2-4 mg when COWS score >8-12
  • Titrate to 8-16 mg daily based on withdrawal symptoms
  • Can be initiated via telehealth with home induction in appropriate cases
  • Maintenance treatment may be required for 5-22 months (average 11 months) 1

Alternative Treatment Options:

• Dihydrocodeine with lofexidine:

  • Effective for shorter, less severe cases of kratom dependence
  • Use a tapering regimen of dihydrocodeine
  • Add lofexidine 0.2 mg 2-4 times daily to manage autonomic symptoms 2

• Supportive medications:

  • Clonidine: 0.1-0.2 mg every 6 hours as needed for autonomic symptoms
  • NSAIDs for pain and myalgias
  • Antiemetics for nausea/vomiting
  • Sleep aids for insomnia

Special Considerations

Dosing Considerations

• No clear correlation exists between daily kratom dose and required stabilization dose of buprenorphine-naloxone 1
• Individual factors such as duration of kratom use and psychological factors may determine the most comfortable maintenance dose 3

Drug Interactions

• Kratom can inhibit CYP2D6, CYP3A, and P-glycoprotein, potentially causing drug interactions 4
• Monitor for increased effects of other medications during withdrawal treatment

Long-term Management

• Consider long-term buprenorphine maintenance for patients with severe kratom use disorder
• Success rates are promising, with 82% of patients testing negative for mitragynine at 12 weeks of buprenorphine treatment 1
• Address underlying reasons for kratom use (pain management, self-medication of anxiety/depression, prior opioid dependence)

Common Pitfalls to Avoid

• Underestimating withdrawal severity: Kratom withdrawal can be significant and require medication-assisted treatment
• Inadequate initial dosing: Insufficient buprenorphine dosing may fail to control withdrawal symptoms
• Too rapid tapering: Gradual dose reduction is essential to prevent recurrence of withdrawal symptoms
• Failure to address polysubstance use: Screen for and address other substance use
• Overlooking psychological factors: Address underlying mental health issues that may have led to kratom use

Follow-up Care

• Regular outpatient follow-up during withdrawal management
• Urine drug testing to monitor for kratom use (mitragynine) and other substances
• Consider referral to addiction specialist for ongoing management
• Psychosocial support and counseling to prevent relapse

Kratom withdrawal should be approached similarly to opioid withdrawal, with medication-assisted treatment being the cornerstone of effective management.